CT-guided Drainage of Deep Pelvic Abscesses via a Percutaneous Presacral Space Approach: A Clinical Report and Review of the Literature

Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study

AIM

The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis.

METHOD

This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage.

RESULTS

Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted.

CONCLUSION

AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Pelvic abscess - to drain or not to drain?

PURPOSE OF REVIEW

Pelvic abscess is a common gynaecological condition, particularly during and after the Covid-19 pandemic, possibly resulting from obstacles to accessing care during this time. To date, no consensus guideline on management exists with a lack of applicable randomized controlled trials (RCTs) comparing medical management with antibiotics alone, image-guided drainage and surgical management, despite this being a potentially life-threatening condition.

RECENT FINDINGS

We present the current literature assessing risks, which contribute to failure of medical therapy, predictive models to guide management and reports of long-term sequelae. Consideration for early laparoscopic or image-guided drainage should be given to women in whom fertility is a priority, pelvic abscess at least 7 cm, white blood cell count on admission more than 16 x 1000/μl, bilateral pelvic abscess, intrauterine device in situ for more than 5.5 years and preexisting endometrioma. Pelvic abscess rupture or severe sepsis should always trigger timely drainage.

SUMMARY

We present the current knowledge on management of pelvic abscesses to help guide clinical practice supported by the most recent evidence. We report the lack of high-quality evidence for many aspects of pelvic abscess treatment and call for well designed large multicentre RCTs to answer the question of which treatment yields the best outcomes.

Low-Dose CT Fluoroscopy-Guided Drainage of Deep Pelvic Fluid Collections after Colorectal Cancer Surgery: Technical Success, Clinical Outcome and Safety in 40 Patients

PURPOSE

To assess the technical (TS) and clinical success (CS) of CT fluoroscopy-guided drainage (CTD) in patients with symptomatic deep pelvic fluid collections following colorectal surgery.

METHODS

A retrospective analysis (years 2005 to 2020) comprised 43 drain placements in 40 patients undergoing low-dose (10-20 mA tube current) quick-check CTD using a percutaneous transgluteal (n = 39) or transperineal (n = 1) access. TS was defined as sufficient drainage of the fluid collection by ≥50% and the absence of complications according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE). CS comprised the marked reduction of elevated laboratory inflammation parameters by ≥50% under minimally invasive combination therapy (i.v. broad-spectrum antibiotics, drainage) within 30 days after intervention and no surgical revision related to the intervention required.

RESULTS

TS was gained in 93.0%. CS was obtained in 83.3% for C-reactive Protein and in 78.6% for Leukocytes. In five patients (12.5%), a reoperation due to an unfavorable clinical outcome was necessary. Total dose length product (DLP) tended to be lower in the second half of the observation period (median: years 2013 to 2020: 544.0 mGy*cm vs. years 2005 to 2012: 735.5 mGy*cm) and was significantly lower for the CT fluoroscopy part (median: years 2013 to 2020: 47.0 mGy*cm vs. years 2005 to 2012: 85.0 mGy*cm).

CONCLUSIONS

Given a minor proportion of patients requiring surgical revision due to anastomotic leakage, the CTD of deep pelvic fluid collections is safe and provides an excellent technical and clinical outcome. The reduction of radiation exposition over time can be achieved by both the ongoing development of CT technology and the increased level of interventional radiology (IR) expertise.

Endocavity Histotripsy for Efficient Tissue Ablation-Transducer Design and Characterization

A 34-mm aperture transducer was designed and tested for proof of concept to ablate tissues using an endocavity histotripsy device. Several materials and two drivers were modeled and tested to determine an effective piezoelectric-matching layer combination and driver design. The resulting transducer was fabricated using 1.5 MHz porous PZT and PerFORM 3-D printed acoustic lenses and was driven with a multicycle class-D amplifier. The lower frequency, compared to previously developed small form factor histotripsy transducers, was selected to allow for more efficient volume ablation of tissue. The transducer was characterized and tested by measuring pressure field maps in the axial and lateral planes and pressure output as a function of driving voltage. The axial and lateral full-width-half-maximums of the focus were found to be 6.1 and 1.1 mm, respectively. The transducer was estimated to generate 34.5-MPa peak negative focal pressure with a peak-to-peak driving voltage of 1345 V. Performance testing was done by ablating volumes of bovine liver tissues ( n = 3 ). The transducer was found to be capable of ablating tissues at its full working distance of 17 mm.

A Novel Transforaminal Approach to Presacral Abscess

BACKGROUND

Presacral abscess is a common disease in the developing countries. Treatments include minimally invasive percutaneous drainage and open surgical debridement. Percutaneous drainage under computed tomography (CT) guidance has been recommended by the American College of Radiology as a good alternative to surgical drainage before elective surgical treatment. Because of the many anatomic obstacles, the presacral space can be one of the most difficult locations to access. There are several reported access routes like transabdominal, transgluteal, transvaginal, transperineal, transanal, precoccygeal, transpedicular, and so on. We introduce a novel approach, the trans-sacral-foramen approach, to drain presacral abscess under CT guidance.

METHODS

A 47-year-old woman who had lumbar laminectomy debridement for epidural abscess was diagnosed with residual presacral abscess. She was placed in the prone position. One-step technique was applied. Intermittent CT scans were obtained during drainage catheter (8F) advancement into the sacral posterior foramen. The stylet was withdrawn and an approximately 60° angle for catheter trajectory was used to best reach the sacral anterior foramen due to the inherent pelvic tilt. When the catheter tip reached the presacral abscess, the abscess cavity was aspirated with a syringe, pus was drained, and catheter was fixed to skin. Sensitive antibiotics were administered.

RESULTS

After 2 weeks magnetic resonance imaging (MRI) showed significant reduced abscess and the catheters were removed. At 18-month follow-up, MRI showed intervertebral fusion at the lumbosacral segment.

CONCLUSIONS

Trans-sacral-foramen approach is the shortest path to reach the presacral abscess. The approach is easier and safer than the others for patients with indication.

Pelvic Abscess after Cesarean Section Treated with Laparoscopic Drainage

Cesarean section (CS), the rate of which is increasing worldwide, may be associated with complications. Although pelvic abscess after CS is rare, it is difficult to treat. We herein report two cases of pelvic abscess treated laparoscopically after CS. The abscesses of the patients were located in the pouch of Douglas and the uterine scar after CS, respectively. Several days after CS, the patients presented with lower abdominal pain and fever. Laparoscopic drainage was performed because imaging revealed a pelvic abscess that was not amenable to drainage through interventional radiology. The patients recovered from infection and were discharged four days after drainage.

Common Options and Overlooked Alternative for Drainage of Inaccessible Presacral Abscess: A Case Report

Purpose.

To demonstrate options and alternative for drainage of inaccessible presacral abscess by the example of a rare clinical case of pyogenic spondylodiscitis, transsacraly drained under a combination of two interventional techniques – CT-guided bone biopsy and abscess drainage.

Materials and methods.

A 55-year-old patient with history of recurrent paravertebral abscesses previously treated with antibiotic therapy was referred to our institution experiencing lower back pain and weakness in both lower extremities. Computed tomography revealed pyogenic spondylodiscitis along with left facet joint destruction and presacral abscess located in ventral sacral surface. Due to inaccessible abscess location, it was decided to perform CT-guided percutaneous transsacral abscess drainage. An 8G bone marrow biopsy needle was used to penetrate the sacrum and create a path for drainage catheter placement. Using the Seldinger technique 8 Fr drainage catheter was inserted into abscess cavity.

Results.

Neither early nor late procedure-related complications occurred. Sixteen days after drainage procedure, the catheter was withdrawn as patient’s condition improved and the outflow of pus had reduced considerably.

Conclusions.

Despite being rarely used, CT fluoroscopy-guided transsacral drainage approach is considered to be minimally invasive and in some cases the only viable option for drainage of pyogenic spondilodiscitis of the lumbosacral junction.

Natural history and therapeutic strategies of post-pancreatoduodenectomy abdominal fluid collections: Ten-year experience in a single institution

TRIAL DESIGN

The aim of this study was to identify independent risk factors for post-pancreatoduodenectomy (post-PD) abdominal fluid collections (AFCs) and evaluate our management protocol on it.

METHODS

A retrospective analysis of consecutive 2064 cases who underwent PD over the past decade in 1 single center was conducted. The patients were divided into AFCs and non-AFCs group. Univariable and multivariate logistic regression analysis was performed to identify independent risk factors of AFCs. The AFCs group was compared with the non-AFCs group with respect to the incidence of postoperative outcomes. The characteristics of AFCs were further analyzed in terms of clinical manifestations.

RESULTS

Two thousand sixty-four cases with pancreaticoduodenectomy were recruited and 15% of them were found AFCs. Diameter of main pancreatic duct ≤3 mm was found to be an independent predictor of AFCs (P < .001), along with soft pancreatic texture (P = .002), mesenterico-portal vein resection (P < .001), and estimated intraoperative blood loss >800 mL (P < .001). The incidence of mild complications was significantly higher in AFCs group than in non-AFCs group (34% vs 20%, P < .001), whereas no significant differences were noted in the rate of severe complications between these 2 groups (15% vs 15%, P = .939).

CONCLUSION

Enhanced drainage is recommended as an effective measure to decrease the incidence of severe complications caused by post-PD AFCs.

CT-guided special approaches of drainage for intraabdominal and pelvic abscesses: One single center's experience and review of literature

BACKGROUND

To explore the safety and efficacy of several special approaches of drainage for deep inaccessible intraabdominal and pelvic abscesses.

METHODS

By searching of our institutional database, the clinical and radiologic information of all patients with special approaches of abscesses drainage was collected, consisting of etiology, diameter of abscess, duration of drainage, major complications, rates of success, failure and death, and pre-procedure, intra-procedure and post-procedure computed tomography scans.

RESULTS

A total of 124 patients are eligible for the criterion in our center between January 2010 and January 2018. The mean diameter of abscess was 5.6 cm (range 3.0-9.8 cm) and mean duration of drainage was 10.3 days (range 4-43 days). Pain was complained in 6 patients (4.8%) and hemorrhage was observed in one patient. Complete resolution of the abscess following drainage was observed in 115 patients (92.7%). A total of 9 patients (7.3%) failed to percutaneous abscess drainage and 3 patients died of catheter-unrelated diseases. Transintestinal afferent loop of drainage was firstly attempted in six patients and complete resolution of abscess was achieved in five patients.

CONCLUSION

Special approaches, including transgluteal, presacral space, transhepatic, multiplane reconstruction (MPR)-assisted oblique approach and transintestinal afferent loop approach for those deep inaccessible intraabdominal and pelvic abscesses are safe and feasible.

[X-ray-surgery of diverticular disease complicated by abscess formation]

PURPOSE

Show the possibility of an alternative use of interventional radiology techniques in complex treatment of patients with inflammatory complications of the diverticular disease of the colon.

MATERIAL AND METHODS

In 2012-2016, there were 87 patients under our supervision with complicated diverticular disease. In 57 (65.5%) cases were diagnosed infiltrate, in 24 (27.6%) cases - abscess of paracolon area (Ib-II type by Hinchey), in 6 (6.9%) cases (III-IV type according Hinchey) generalized peritonitis have been identified.

RESULTS

Emergency laparotomy was performed in 13 patients. Abscesses of paracolon (Ib-II type by Hinchey) area were diagnosed sonographically during the initial examination in 17 patients. 26 percutaneous drainage of diverticulogenous abscesses of different localizations self-locking drainage #8Fr 'pig tail' was carried out under the combined ultrasonic and X-ray control in this group of patients. The technical success of percutaneous drainaging of the abscesses was achieved in all manipulations. 13 patients had a single drainaging, and for diverticular disease - disease-free during the observation period of 1 year to 5 years. Resection of the colon in a planned manner after percutaneous drainage of recurrent abscess of paracolon area was performed in 4 patients. Complications related with the technique of installing drainage were not reported, mortality in the group of drained patients was absent.

CONCLUSION

Ultrasound examination of patients with suspected inflammatory complications of diverticular disease - a necessary and sufficient method for initial diagnosis of the disease. Percutaneous drainage of diverticulogenous abscesses (Hinchey Ib-II) is represented by the pragmatic 'first line' choice in patients with complicated diverticular disease, that allows to treat the pathology steadfastly in most of the cases.